Telemedicine Videoconferencing and Telehealth Informed Consent
After intake and establishment of a therapeutic relationship, it may be possible for treatment delivery to occur via interactive videoconferencing (i.e., virtual “face-to-face” sessions) in lieu of or in addition to “in person” sessions. Video Conferencing (VC) is a real-time interactive audio and visual technology that allows us to provide mental health services remotely. We will use doxy.me a HIPAA compliant VC platform, although we will reserve the right to change platforms due to technical issues. We will only use a HIPAA compliant platform for this service.
The benefits of participating in VC therapy may include reduced time to participate in therapy without need to commute to the our office, as well as the possibility of more flexibility in scheduling sessions. However, for VC to be effective, there are also special considerations and risks to take into account. These include:
• Prior to offering VC services, we require a minimum of initial evaluation and 3 sessions to assess your suitability for VC services. We do NOT offer VC services to those whom I have not performed an in-person assessment.
• Set up: You will need access to and familiarity with the appropriate technology to participate in VC services. We will review this with you in person prior to the start of our VC sessions. However, ultimately it is your responsibility to ensure that you are set up adequately. Considerations that you should take into account include but are not limited to the following:
Ø Location- Please take steps to ensure you have a quiet, private place, free from distractions in order to participate effectively in VC sessions.
Ø During the sessions you will need a reliable internet connection and a computer (tablet or mobile device) with a video or web camera.
Ø You should be aware of potential issues with your computer. Although I will use a HIPAA compliant platform that uses encryption and has privacy protections, there remain risks in transmitting information over the internet. These include possible breaches of confidentiality, theft of information or disruption of service due to technical difficulties.
Ø Efficacy- In participating in VC services, I agree to regularly reassess with Dr. Leifer the appropriateness of continuing to deliver/receive services via VC. This includes checking in on how the technology may be impacting delivery of service and what we do about it when it does. It also includes your personal perceptions about how therapy via VC feels for you. If we are unable to resolve technological issues we will need to transition your therapy to traditional in-person treatment. In signing this consent, you agree to periodically make time during sessions do assess these issues.
• Exceptional situations:
Ø In emergency situations if you require assistance you will need to access care locally by calling 911, your local crisis line or by going to your nearest hospital emergency room. A 24x7 crisis hotline number to keep on hand is: 1-844-493-8255
Ø Should service be disrupted, we may need to reschedule or resort to other means of communication. For sessions lasting more than 15 minutes at time of disruption, the session will be billed on a pro-rated basis. If you are submitting for insurance reimbursement, please check with your insurance ahead of time as they may not reimburse for sessions that are disrupted or finished via means other than VC.
• Process: This is a new method of delivering service that was urgently implemented due to the Corona Virus Pandemic of March, 2020. While research shows that it can be very effective, it is not appropriate for all. If we assess that it is not beneficial, suitable or effective, we will discuss this with you. We will then work with you on an alternative continuity of care plan.
• Records: We will continue to document and keep records of our sessions as we have with face-to-face sessions.
• Reporting requirements: All mandated reporting requirements regarding child, elder and dependent abuse, as well as suicidal and homicidal risk are still in effect.
• Fees: Our sessions are fee-for-service only with payment due at the time of each session. We do not take insurance but we are happy to provide a Health Insurance Claim Form (HCFA or Superbill) with appropriate coding for VC sessions. As always, check with your insurance prior to start of sessions to understand what they cover.
· You may refuse telemedicine services at any time, without loss or withdrawal of treatment. All applicable confidentiality protections shall apply to these services. You shall have access to all medical information from these services per our Office Policies and state law.